How patients perceive their glaucoma matters

The other day, I had the pleasure of seeing one of my favorite glaucoma patients for an intraocular pressure (IOP) check and visual field study. She is an 86-year-old white female from rural Nebraska who found her way to Georgia many years ago with her late husband in an attempt to find carpentry work. She has no family here and is essentially independent, living alone, and still driving. Her medical history is remarkable for arterial hypertension and high cholesterol, and her systemic medications are Lipitor (atorvastatin calcium, Pfizer) and Tribenzor (olmesartan medoxomil/amlodipine/hydrochlorothiazide, Daiichi Sankyo). 

I have been successfully treating her IOP with prostaglandin analog monotherapy for two years. She first presented with IOPs of 28 mm Hg in the right eye and 29 mm Hg in the left eye. After a diagnosis of early primary open-angle glaucoma, I set her target pressures to 18-21 mm Hg for both eyes, corresponding to about a 30 percent IOP reduction. She has consistently been at or below target since the initiation of therapy.

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The big question

She had just started the Tribenzor and asked me if I thought it could affect her glaucoma. I told her that amlodipine, being a calcium channel blocker, was actually helping by opening up the blood vessels feeding her optic nerves. At the completion of the examination, I was getting ready to walk her up to the front when she stopped me and said she had a very serious question. We both sat down, and she asked me how long she had before she went blind because her mother went blind from glaucoma before seeking ophthalmic care. My mind immediately went back to my fourth year at University of Alabama at Birmingham School of Optometry in the ocular disease clinic when a patient asked me the very same thing. I froze up at the time because I didn’t really know how to handle such a blunt and potentially life-altering question.

My attending, Dr. Nowakowski, who was in the room, sensed the feeling of tension in the air and immediately jumped in by emphatically saying, “No. We’re not going to let that happen.” He then went on to briefly say that the patient was doing everything she needed to do with her drops and to simply continue being compliant. I could literally see the relief appear on the patient’s face. I felt relieved, as well, and I never forgot about that short 10-second conversation. 

Next: Lessons learned

Lessons learned

I took two lessons away from that day in clinic. The first lesson I learned was the fact that patients tend to perceive information in a much different way than doctors. Further, in the age of the Internet and its seemingly unending ether of information, it’s not difficult to search long enough to convince oneself that a particular symptom or diagnosis carries with it an impending sense of doom.

The second lesson I learned on that day was the fact that many patients tend to look to their doctors for a sense of comfort. As fiduciaries, doctors have an obligation to explain what is going on with their patients’ health, and glaucoma can and often does lead to blindness with no treatment (or treatment that is ineffective). 

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Moreover, the “I feel fine, so this must not be a big deal” mantra is still very much alive and well in glaucoma, and some patients truly need to be rattled about the seriousness of their condition. However, passing up an opportunity to give reassurance in the face of paranoia means passing up an opportunity to potentially make a big difference in one’s mindset, noting that appropriate levels of concern and understanding of one’s condition can lead to better compliance (and, thus, better overall health). In short, never pass up an opportunity to give a patient good news, so long as it is rational.

Next: I'm not going to let that happen

I’m not going to let that happen

Turning back to my present glaucoma patient’s sinister question, I simply said, “You’re not going blind from glaucoma because I’m not going to let that happen. At this point, you and I are doing everything we need to do to prevent that from happening. So, let’s just keep up the good work.” She smiled and thanked me, and I walked her up to the front desk to schedule an IOP check for three months down the road.

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Taking care of patients’ eyes, adnexa, and visual systems can be challenging enough, as it is.  However, the science of what we do, as optometrists, is often one of the easiest parts of our days. It is the art of conveying information to our patients in an appropriate manner (and dealing with subsequent reactions) that can be delicate to handle. I learned much regarding this concept (among many other things) from Dr. Nowakowski, and I have come to realize that people tend to get more bad news than good news from doctor visits. This notion could be framed to especially reign true in the arena of glaucoma, when the goal of therapy, to this date, really isn’t to improve function, but to just keep things from getting worse. Again, never pass up an opportunity to give a patient good news (keeping in mind the fact that news of blindness not being imminent may be just good enough).

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